Nurses Face Higher-Than-Average Suicide Risk

Also see MedPage Today's earlier investigation series, "Nurse Suicide: Under the Radar," for more background on nurse suicide.

The first national longitudinal study of nurse suicide in the U.S. found that nurses were substantially more likely than others to take their own lives.

Female nurses were found to be 1.4 times more likely to complete suicide than the general population (incidence rate ratio 1.395, 95% CI 1.323-1.470, P<0.001). For male nurses, the IRR was 1.205 (95% CI 1.083-1.338, P<0.001).

"We do know that suicide amongst nurses is a real issue and that the job has something to do with it," the study's lead author, Judy Davidson, RN, DNP, of the University of California San Diego (UCSD), told MedPage Today.

Appearing in Worldviews on Evidence-based Nursing, the study drew on data from the CDC's National Violent Death Reporting System. In all, the researchers collected and analyzed death data from 1,824 nurses and 152,495 non-nurses who took their lives from 2005 to 2016.

To estimate the total population of nurses -- the denominator, which made calculating an incidence rate possible -- the team collected reports from the National Council of State Boards of Nursing and individual state boards.

Davidson and colleagues also examined nurses' methods of suicide and possible risk factors and provided recommendations for policymakers and implications for future research.

The researchers pointed to three factors that were more common among nurses than in others committing suicide:

• Job problems

• Mental health history

• Leaving a suicide note

Pharmacological poisoning was the most common means of suicide among female nurses (27.2%), followed by firearms (22.7%), non-drug poisoning (17.3%), and hanging/asphyxiation (12.5%); for 14.9%, the method was unrecorded.

For males, in contrast, firearms were far and away the most common means (41.7%), with hanging/asphyxiation responsible for 12.1%; method was unknown for 20.8% of male nurse suicides.

The vast majority of nurses who died by poisoning used "prescribed medications or medicine that could be prescribed" and not illicit street drugs, Davidson said. She added that there were "a few" cases of cocaine use but much more frequently the drugs used were opiates and benzodiazepines likely to have been prescribed to the individual. A fraction of 1% involved medications diverted from a hospital environment, she said.

Davidson noted that nurses are known to have a higher risk of physical health problems than the general population, including musculoskeletal injuries incurred on the job.

However, the study also suggested that substance use may be under-reported among nurses: "We need better mechanisms of ... identifying nurses with substance use disorders, and treating them in a holistic manner and welcoming them back into the workforce once treated," Davidson said.

Workplace Stressors

She called the findings about workplace stressors "keenly important."

"A lot of us would like to believe it's the home issues driving these people over the edge, but I've triangulated the data now, and I feel fairly confident that there's something in nursing as a profession that needs to be fixed to decrease the risk," Davidson told MedPage Today.

The odds ratio of having a job problem was 1.99 (95% CI 1.695-2.325, P<0.001) in female nurses who died by suicide and 1.81 in male nurses (95% CI 1.380-2.359, P<0.001).

Davidson also co-authored an accompanying study of a suicide prevention program at UCSD, called Healer Education Assessment and Referral (HEAR), which analyzed data from open-ended questions that screened for nurses' risk of depression, burnout, and suicide. Both studies indicated that work-related issues are associated with nurse suicide, with the HEAR analysis echoing many of the national findings. (See related story with details on the HEAR analysis.)

Some of these work-related stressors include inadequate preparation for nurses' roles, poor working relationships between managers and subordinates, violence against nurses by patients and other visitors, and the burden of requests to work overtime hours.

Over-regulation is another significant work-related stressor. Davidson cited new standards on medication management issued by the Joint Commission, as one example. "If [nurses] go outside of the written order, they're violating accreditation standards, and if they follow the accreditation standards they're delaying care," she said.

History of Mental Illness

Davidson and colleagues also found that nurses were more likely to have a history of mental health problems compared with the general population (OR 1.126, 95% CI 1.013-1.253, P<0.027 for females; OR 1.30, 95% CI 1.048-1.614, P=0.016 for males).

Nurses who took their own lives were also more likely to be receiving mental health treatment. Still, there could be an "aberrancy" in the data, Davidson speculated.

For example, the assumption may be that any nurse taking mental health-related medications is in fact undergoing care, but that may not be true, Davidson said. It's possible these nurses were merely prescribed medications by a general practitioner and weren't receiving counseling or psychotherapy.

The odds of leaving a suicide note were also higher among nurses than non-nurses, with odds ratios of 1.22 for female nurses and 1.76 for male nurses. Davidson said she wasn't certain what to make of this detail. But the idea that nurses are communicating their feelings in these suicide notes could mean that "maybe ... they were ready to talk about it. You just wonder if you had found them sooner if we could have prevented the occurrence," she said.

Rachael Accardi, LMFT, a HEAR program therapist and coordinator who co-led the program's analysis with Davidson, suggested that these notes may be reflective of nurses' deeply caring nature: "Even in the face of suicide, I think they're probably also thinking of their loved ones' well-being," she told MedPage Today via email. "Maybe a suicide note is a nurse's way of making sure those loved ones are soothed ... even if it's just a little after their death."

Implications for Healthcare Leaders, Future Research

Asked what message her research could have for hospital administrators, Davidson said the data makes the case that administrators should "strip the workplace of unnecessary rules, [and] regulations ... and make the workplace as friendly an environment as possible."

She also stressed the importance of training leaders and mid-level managers in caring practices.

Davidson pointed out that the younger generation of nurses has higher rates of anxiety and depression at baseline: "This is not going to get better magically ... We have to brace ourselves, and do some hard work to be able to proactively reach out to those people and get them help to build resiliency, so that we do have a workforce to care for the sick and injured in the community."

In addition, Davidson said her wish is for administrators to know that the UCSD HEAR program for suicide prevention is easily replicable: "It's not complex, it's not hard to do, and it doesn't take a lot of money."

It would also enable hospitals to identify at-risk nurses and get them into care, Davidson added.

As for future research, Davidson will be working with a researcher whose expertise is in natural language processing to perform qualitative analysis of law enforcement and medical examiner reports of nurse suicide to identify any meaningful information that can guide prevention strategies.

In addition, the American Nurses Association recently formed a suicide prevention committee, co-chaired by Davidson and Bernadette Melnyk, PhD, RN, of Ohio State University's College of Nursing in Columbus, which will prepare suicide-prevention resources for the nurse community.

If you or someone you know is considering suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255.

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